Information Collection

Provider Survey

IC 216768 under ICR 202504-2900-020 · OMB 2900-0843.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 10-10162 Provider Survey	Form and Instruction
Form 10-10162 CHALENG Survey - Provider Provider Survey	Form and Instruction
10-10162 CHALENG Survey - Provider 2900-0843 Survey (Provider) 2024-11-18.docx	Form and Instruction
10-10162 CHALENG Survey - Provider 2900-0843 Survey (Provider) 2024-11-18.docx	Form and Instruction

IC Title:

Provider Survey

Agency IC Tracking Number:

2900-0843

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	10-10162				Yes	No	Fillable Printable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,200

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	3,200	3,200
Annual IC Time Burden (Hours)	320	320
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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